PHTLS - Prehospital Trauma Life Support Airway and Ventilation — Questions and Answers
Question 1: Which airway adjunct is most appropriate for an unconscious trauma patient with an intact gag reflex?
- Oropharyngeal airway (OPA)
- Nasopharyngeal airway (NPA) (Correct answer)
- Laryngeal mask airway
- Combitube
Correct answer: Nasopharyngeal airway (NPA)
The nasopharyngeal airway is better tolerated than the OPA in patients with an intact gag reflex.
The NPA is inserted through the nostril and sits in the posterior pharynx, bypassing the tongue to maintain airway patency. Unlike the OPA, it is generally tolerated by patients with intact gag reflexes. PHTLS recommends sizing the NPA by measuring from the nostril to the earlobe.
Question 2: What is the primary risk of hyperventilation in a trauma patient with a head injury?
- Gastric distension leading to vomiting
- Cerebral vasoconstriction causing decreased cerebral perfusion (Correct answer)
- Pulmonary edema from over-inflation
- Cardiac arrhythmia from respiratory alkalosis
Correct answer: Cerebral vasoconstriction causing decreased cerebral perfusion
Hyperventilation causes hypocapnia leading to cerebral vasoconstriction, which reduces cerebral blood flow and can worsen secondary brain injury.
Carbon dioxide is a potent cerebral vasodilator. Hyperventilation rapidly lowers PaCO2, causing cerebral vasoconstriction. PHTLS recommends normal ventilation rates for TBI patients. Mild hyperventilation is ONLY indicated when signs of cerebral herniation are present.
Question 3: In PHTLS, what is the jaw thrust maneuver primarily used for?
- Opening the airway in patients with suspected cervical spine injury (Correct answer)
- Clearing a foreign body obstruction
- Inserting an endotracheal tube
- Assessing mandibular fractures
Correct answer: Opening the airway in patients with suspected cervical spine injury
The jaw thrust opens the airway by displacing the mandible anteriorly without extending the neck, making it the preferred technique when cervical spine injury is suspected.
The jaw thrust is performed by placing fingers behind the angles of the mandible and lifting forward. Unlike the head-tilt chin-lift, the jaw thrust maintains cervical spine alignment. PHTLS emphasizes that if the jaw thrust alone does not open the airway, a careful head-tilt chin-lift should be performed since airway patency takes priority.
Question 4: What is the preferred initial ventilation method for a trauma patient requiring assisted ventilation in the field?
- Mouth-to-mouth ventilation
- Bag-valve-mask with supplemental oxygen (Correct answer)
- Demand valve resuscitator
- Mechanical ventilator
Correct answer: Bag-valve-mask with supplemental oxygen
Bag-valve-mask ventilation with supplemental oxygen provides effective ventilation with high FiO2 delivery.
The BVM with supplemental oxygen is the mainstay of prehospital ventilation. Connected to a reservoir and oxygen at 15 L/min, it delivers near 100% FiO2. PHTLS teaches that BVM ventilation is often a two-person technique in the field.
Question 5: Which clinical sign indicates a potentially compromised airway in a trauma patient?
- Clear, strong voice
- Stridor or gurgling sounds during breathing (Correct answer)
- Respiratory rate of 16 breaths per minute
- Equal bilateral chest rise
Correct answer: Stridor or gurgling sounds during breathing
Stridor indicates upper airway narrowing and gurgling suggests fluid in the airway, both signs of airway compromise requiring immediate intervention.
Stridor is a high-pitched inspiratory sound indicating upper airway narrowing. Gurgling suggests blood, vomit, or secretions requiring immediate suctioning. Hoarseness may indicate laryngeal injury. PHTLS emphasizes that an awake patient who can speak clearly likely has an adequate airway.
Question 6: According to PHTLS, what is the appropriate oxygen saturation target for trauma patients?
- 88-92%
- Greater than or equal to 94% (Correct answer)
- 100% at all times
- 85-90% is acceptable
Correct answer: Greater than or equal to 94%
PHTLS recommends maintaining oxygen saturation at 94% or above in trauma patients to ensure adequate tissue oxygenation.
This threshold ensures adequate hemoglobin saturation and tissue oxygenation. Patients with TBI should maintain SpO2 above 90% as even brief hypoxic episodes significantly worsen neurologic outcomes.
Question 7: A trauma patient with facial burns develops progressive hoarseness and stridor. What does PHTLS recommend?
- Monitor closely and transport; intubation can wait
- Early definitive airway management before complete obstruction occurs (Correct answer)
- Administer nebulized epinephrine and observe
- Apply supplemental oxygen only and reassess
Correct answer: Early definitive airway management before complete obstruction occurs
Progressive hoarseness and stridor in a burn patient indicate developing airway edema that may rapidly progress to complete obstruction.
Thermal airway injury produces progressive edema that can completely occlude the airway within hours. PHTLS emphasizes early airway management because once edema progresses, visualization of landmarks becomes impossible.
Question 8: What complication should be anticipated when using a supraglottic airway device in a patient with active upper airway bleeding?
- Device malfunction from blood exposure
- Aspiration of blood around an imperfect seal (Correct answer)
- Automatic deflation of the device cuff
- Increased intracranial pressure
Correct answer: Aspiration of blood around an imperfect seal
Supraglottic devices do not provide a definitive seal around the trachea, so active bleeding can track around the device and be aspirated.
Supraglottic airway devices sit above the glottis and create a seal around the laryngeal inlet rather than within the trachea. In patients with active upper airway bleeding, blood can track past the seal and enter the trachea. Endotracheal intubation or surgical airway provides superior protection.
Question 9: PHTLS teaches that which trauma mechanism most frequently leads to airway compromise?
- Isolated extremity fractures
- Maxillofacial trauma with bleeding and structural disruption (Correct answer)
- Blunt abdominal trauma
- Simple rib fractures
Correct answer: Maxillofacial trauma with bleeding and structural disruption
Maxillofacial trauma commonly causes airway compromise through structural disruption, bleeding, loose teeth or bone fragments, and soft tissue swelling.
Maxillofacial trauma threatens the airway through multiple mechanisms: mandibular fractures can cause the tongue to fall posteriorly; midface fractures cause massive bleeding; loose teeth become foreign bodies; and soft tissue swelling progressively narrows the airway.
Question 10: What is the recommended technique for suctioning a trauma patient's airway?
- Continuous suctioning for 30 seconds at a time
- Intermittent suctioning for no more than 10 seconds at a time in adults (Correct answer)
- Suctioning only during inhalation phase
- Deep tracheal suctioning without pre-oxygenation
Correct answer: Intermittent suctioning for no more than 10 seconds at a time in adults
Suctioning should be limited to 10-second intervals in adults to prevent hypoxia, with pre-oxygenation when possible.
PHTLS recommends limiting suctioning to 10 seconds per attempt in adults because the suction catheter removes oxygen along with debris. A rigid-tip Yankauer suction catheter is preferred for clearing the oropharynx of blood, vomit, and debris.
Question 11: According to PHTLS, when is a surgical cricothyrotomy indicated in a trauma patient?
- As the first-line airway management technique for all trauma
- When the airway cannot be secured by any other method and ventilation is inadequate (Correct answer)
- Only when the patient is in cardiac arrest
- Whenever endotracheal intubation fails on the first attempt
Correct answer: When the airway cannot be secured by any other method and ventilation is inadequate
Surgical cricothyrotomy is the final step in the 'cannot intubate, cannot oxygenate' pathway when all other airway methods have failed.
The procedure involves identifying the cricothyroid membrane, making a horizontal incision, and inserting a small cuffed tube. It is contraindicated in children under 12. Common scenarios include massive facial trauma and severe airway edema.
Question 12: What is the significance of end-tidal CO2 monitoring (capnography) in prehospital trauma care?
- It only confirms endotracheal tube placement
- It provides continuous monitoring of ventilation adequacy, perfusion status, and tube position (Correct answer)
- It replaces pulse oximetry entirely
- It is only useful during CPR
Correct answer: It provides continuous monitoring of ventilation adequacy, perfusion status, and tube position
Capnography provides continuous data on ventilation adequacy, confirms airway device placement, monitors perfusion status, and can detect deterioration in real time.
Beyond confirming ETT placement, capnography continuously monitors ventilation rate, cardiac output trends, metabolic status, and tube displacement. Falling ETCO2 despite adequate ventilation suggests deteriorating perfusion, an early warning that may precede pulse oximetry changes by minutes.
